Developing equity-focused interventions for maternal and child health in nigeria: An evidence synthesis for policy, based on equitable impact sensitive tool (EQUIST)

Introduction: among the most critical health systems components that requires strengthening to improve maternal, newborn and child health (MNCH) outcomes in Nigeria is the concept of equity. UNICEF has designed the equitable impact sensitive tool (EQUIST) to enable policymakers improve equity in MNCH and reduce disparities between the most marginalized mothers and young children and the better-off. Methods: using the latest available DHS data sets, we conducted EQUIST situation and scenario analysis of MNCH outcomes in Nigeria by sub-national categorization, wealth and by residence. We then identified the intervention package, the bottlenecks and strategies to address them and the number of deaths avertible. Results: EQUIST profile analysis showed that the number of under-five deaths was considerably higher among the poorest and rural population in Nigeria, and was highest in North-West region. Neonatal causes, malaria, pneumonia and diarrhoea were responsible for most of the under-five deaths. Highest maternal mortality was recorded in the North-West Nigeria. Ante-partum, intrapartum and postpartum haemorrhages and hypertensive disorder, were responsible for highest maternal deaths. EQUIST scenario analysis showed that an intervention package of insecticide treated net can avert more than 20,000 under-five deaths and delivery by skilled professionals can avert nearly 17,000 under-five deaths. While as many as 3,370 maternal deaths can be averted by deployment of skilled professionals. Conclusion: scaling up integrated packages of essential interventions across the continuum of care, addressing the human resource shortages in rural area and economic/social empower ment of women are policy recommendations that can improve MNCH outcomes in Nigeria.

Nigeria has a total area of 923,768 km2 and is located on the Gulf of Guinea of West Africa and lies between latitudes 4° and 14°N, and longitudes 2° and 15°E. The country is divided into six geopolitical zones including North-West, North-Central, North-East, South-West, South-East and South-South and comprises 36 states and the Federal Capital Territory, Abuja as the capital [18]. The states are divided into 774 local government areas (LGAs). With approximately 186 million inhabitants in 2016, Nigeria is the most populous country in Africa and the seventh most populous country in the world [19]. Being the most populous country with high fertility rate, Nigeria has third-largest young population in world, after India and China, with up to 44% of the population under 15 years of age [20]. Nigeria is the largest economy in Africa, with a GDP greater than USD 500 billion and steadily grew to over 7 percent per annum between 2005 and 2014, but this growth has been slower in 2015 [21]. Ironically, poverty is still pervasive in Nigeria, where recent figures indicate 68% of the population lives on less than US$1.25 a day [20]. The Nigeria health profile is shown in Table 1. Great disparities in health status exist, across the states and geopolitical zones of the country and disease aetiology is linked to social determinants such as socio-economic status, education, gender inequality, as well as poor access to water, sanitation and hygiene [20]. Health care delivery in Nigeria is a concurrent responsibility of the three tiers of government in the country (federal, state and LGAs), as well as the private sector. Nigeria health systems was ranked 187th in the world in 2000 [22] but within the last 15 years, various health indicators have shown steady, albeit slow, improvement. Health profile of Nigeria We used the 2013 DHS data sets for Nigeria which are the latest pre-loaded in EQUIST to perform both situational and scenario analysis. The analysis was conducted as instructed in the EQUIST user guide [23]. Using the sub-national (geo-political zones), wealth (richest to poorest quintiles) and residence (urban and rural) categorization, we performed EQUIST situational (profile and frontier) analysis to determine maternal, neonatal and under-five mortality in Nigeria. The EQUIST profile analysis is categorized into sector and theme. The sector category is further divided into demographic and epidemiological parameters, while the theme category is divided into family care practices, preventive services and curative services. We assessed the under-five mortality and the neonatal mortality in Nigeria and related them to the key drivers, the underlying factors and the scale of the inequities. This was achieved by the analysis of the demographic parameters of the sector category. The analysis was used to provide information on the following: (a) the part of Nigeria that recorded the highest child (under-five and neonatal) mortality and considered the most deprived in terms of MNCH interventions; (b) the most disadvantaged or vulnerable children; i.e. how deprivation is affected by various drivers such as wealth, geography, and location; (c) the health conditions that cause excess mortality among the most disadvantaged populations; and (d) the health interventions that are linked to this excess mortality in the most deprived areas. We analysed the epidemiological parameters of the sector category, and identified the main diseases responsible for under-five, neonatal and maternal mortality. We also analysed the theme category, to determine the level of effective package coverage of family care practices, preventive services and curative services. We related these to the various zones in Nigeria to identify the population that is mostly affected by sub-national categorization, wealth and residence. We performed EQUIST scenario analysis for the North-West region of Nigeria. First, we assessed the main epidemiological causes of under-five mortality and maternal mortality in the region (prematurity and asphyxia). Second, we identified interventions considered as priorities that can address the epidemiological causes of under-five and maternal mortality, grouped in “packages” under family care practices (ITN ownership and use), preventive services (DPT3 immunization), and curative services (delivery by skilled professionals). Third, we determined the major possible bottleneck (geographical accessibility) that can constitute potential impediment to the identified intervention. We assessed the severity, how they affect utilization of the intervention packages and coverage and the strategies to address them. Four, we analysed the enabling environment that can facilitate the strategies for addressing bottlenecks from the perspective of the health systems building block components (task shifting, redeployment/relocation existing staff, non-facility service provision, lay/community health worker service delivery, contracting out). Five, we performed impact analysis to determine the number of avertible under-five and maternal deaths.

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